Management of congenital dacryocystocele: report of 3 clinical cases.

This case study describes three newborns referred to our otolaryngologic service for investigating and treating a cystic dilatation of the lacrimal duct. These dilatations corresponded to unilateral or bilateral dacryocystoceles, with or without complications. The first newborn exhibited respiratory distress at birth and received early surgery and endoscopic marsupialization of intranasal and bilateral cysts. The second newborn did not show any signs of complications, and after conservative treatment for a week, the cyst spontaneously resolved. The third newborn was diagnosed in utero with ultrasonography, and the cyst resolved spontaneously during childbirth. These cases provided an opportunity to review the pathophysiology of this rare congenital lacrimal anomaly and to note responses to different therapeutic approaches. Indeed, these three cases illustrated three different management approaches, and allowed us to address the issue of prenatal diagnosis.

[When rhinosinusitis reveals a systemic disease]. / Quand la rhinosinusite révèle une pathologie systémique.

This retrospective analysis is concerned with 10 patients suffering from granulomatosis with polyangitis (GPA, Wegener's disease), who were followed up in a tertiary care Ear, Nose, and Throat (ENT) department. The inaugural events took place in the ENT field (8 patients), the lung (2 patients), the vestibule (1 patient), or the oral cavity (1 patient). The ENT manifestations during the disease evolution involved the rhinologic (osetocartilaginous--6 cases; mucosal--9 cases), the otologic (3 cases), or the laryngeal area (2 cases). Facial pain was noted in 6 cases and residual hyposmia in 5. We observed 5 cases of lung involvement, 3 cases of renal involvement, and 4 cases of ocular involvement. An aseptic meningitis was seen in 1 case and the muscles were affected in 6 cases. The average delay between symptom onset and diagnosis was 26 months. Endoscopy, imaging techniques, and determination of antineutrophil antibodies (ANCA) were used to reach the diagnosis. Sinus biopsies were contributive in 6 cases. The patients were treated with immunosuppressive drugs and/or surgery. After treatment, remission was obtained in 6 patients.

Traumatic, iatrogenic, and spontaneous cerebrospinal fluid (CSF) leak: endoscopic repair.

Over the past two decades, Cerebrospinal Fluid (CSF) leak repair has advanced from open invasive intracranial approaches to transnasal endoscopic ones that avoid the traditional morbidities of frontal craniotomy approaches--such as anosmia, intracranial haemorrhage or oedema, seizures, memory deficiencies, and behaviour disorders--reducing morbidity, reducing hospitalisation times and accelerating return to work, and therefore cutting indirect costs. The diagnosis of CSF rhinorrhoea is both clinical and radiological. The presence of CSF in clear nasal drainage should be established by analysis for CSF markers. Localisation of the leak site involves radiological investigation, mainly Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI). In addition to suppressing symptoms, the main goal of the closure of CSF rhinorrhoea is to prevent ascending meningitis. The operative management of cerebrospinal fluid leak is advised in the following circumstances: persistent, posttraumatic CSF leaks after 4 to 6 weeks of conservative treatment; all cases of spontaneous CSF fistulae; cases with intermittent leaks; delayed posttraumatic leaks; cases of CSF leak with a history of meningitis; false CSF rhinorrhoea coming from the petrous bone via the Eustachian tube. The graft material used depends mainly on the authors' experience and did not significantly influence the success rate. The main steps in the surgical procedures do not differ as much from one author to the other: accurate localisation of the defect; creation of a raw surface around the defect to accept the graft and to help in the formation of synechiae to support the seal later; plugging of the defect with fat covered with fascia lata supported by absorbable gelatin and Merocel. The differences between the authors relate to the use of fluorescein to locate the defect, the importance of prophylactic antibiotherapy, the plugging materials, the technique of underlay or overlay grafting, the use of fibrin glue and the need for lumbar drainage. The success rate for endoscopic repair of CSF rhinorrhoea is high: approximately 90% at the first attempt. Recent reports in the literature highlight the group of patients with spontaneous idiopathic CSF leak as a group with specific attributes and treatment challenges.

Type III frontal sinusotomy: surgical technique, indications, outcomes, a multi-university retrospective study of 120 cases.

Draf in 1991. The procedure--which is also known as the modified endoscopic Lothrop procedure--aims to create the largest possible anteroposterior and lateral to lateral opening between both frontal sinuses and the nasal cavities. This requires the resection of the medial floor of both frontal sinuses, the intersinus septum and the superior nasal septum. The authors present a retrospective study including a cohort of 120 patients who underwent surgery in six Belgian university ENT departments. Mean follow-up was 24.6 months (range: 5-36 months). This paper describes the surgical procedure and reviews the indications, comorbidities, outcomes and complications of the type III frontal sinusotomy. Some correlations are also established with the data published in the worldwide literature. The authors conclude that the Draf III is a demanding procedure requiring considerable expertise in endoscopic sinus surgery. The procedure is effective with a success rate of 87.5%. Indeed, 12.5% of patients only experienced closure of the neoostium while 20% of all the patients had unchanged or worse symptomatology. The percentage of post-operative complications is 7.5%. All complications were managed successfully.

Rhinoplasty outcome measurement.

The literature includes few publications dealing with the measurement of rhinoplasty outcomes. We also lack reliable instruments for such measurements. In a population of 228 patients who underwent rhinoplasty performed by the same surgeon, we evaluated patient satisfaction using Alsarraf's questionnaire and an evaluation of cosmetic improvement using standardised pre- and post-operative photographs (Photograph Score from 1- great to 7- monstrous). We correlated these data with the severity of the pre-operative nasal deformities, (Predictable Difficulty Score) with the complexity of the surgical procedure, (Surgical Complexity Score) and with four specific surgical procedures (Spreader Grafting, Domal Interruption, Grafting of the Dorsum, Tip Grafting). Both Alsarraf's questionnaire and the photograph score identified a significant difference between the pre-operative and post-operative data and appear to be reliable instruments for measuring patient satisfaction. The questionnaire takes into account the functional outcome that the PS did not. In our hands, the mean improvement evaluated by the questionnaire was 50.2%, and 2.8 according to the PS, regardless of primary or revision surgery, traumatic or non-traumatic nose, mixed cosmetic/functional or purely cosmetic goals. The relative size of the difference between the pre- and post-operative scores was linked more to the satisfaction of the patient than to the absolute post-operative level. These two instruments (the questionnaire and the photograph score), although they are in agreement, did not allow for the establishment of any correlation between the satisfaction of the patient and the predicted difficulty score (PDS), the surgical complexity score (SCS), or three of the four specific procedures that were considered (SG, DI, GD and TG). Domal interruption was the only procedure in which we found that patient satisfaction was higher than with the other procedures (65.6% for the questionnaire and 3.8 for the photograph score).

Rhinomanometry and acoustic rhinometry in rhinoplasty.

Acoustic rhinometry (AR) and rhinomanometry (RMM) study two different parameters of nasal ventilation: respiratory function and the anatomy of nasal cavities. This article looks at their usefulness, in particular in the surgical field. We list the normal values for these tests. Nasal obstruction is a symptom of multifactorial origin. Nasal patency is only one factor influencing the sensation of nasal ventilation. Despite the range of divergent opinions in both the literature and among rhinological clinicians, the objective assessment of nasal patency in functional rhinoplasty or septorhinoplasty seems to be advisable. The roles of AR and RMM still have to be established.

A review of nasal dorsal hump reduction techniques, with a particular emphasis on a comparison of component and composite removal.

Nasal dorsal hump reduction is a frequently performed and basic step in non-functional rhinoplasty. The literature has described multiple techniques for nasal hump removal. However, most of the descriptions consider new or modified techniques. No papers have been published comparing any of these different surgical interventions. The aim of this paper is to review several techniques in common use, looking at their inherent advantages and disadvantages in the light of the authors' personal experiences. Particular attention is devoted to a comparison of component and composite hump reduction. The latest trends in hump removal techniques aim for predictable and realistic results with pleasing aesthetic outcomes based on precise resection techniques and the optimal preservation of nasal anatomy and function.

Consensus in rhinoplasty.

Reading textbooks or manuals about rhinoplasty techniques, the novice may be disconcerted by the multitude of different surgical manoeuvres, all intended to achieve the same result: a cosmetically appealing and functional nose. This article describes a survey of 30 rhinoplasticians that investigated, using a questionnaire with 51 items, current opinion and practice in rhinoplasty with the aim of identifying areas of consensus or disagreement. Only 16 questions in 51 (31%) identified a strong consensus, mainly in the areas of informed consent, lateral osteotomies, and the accuracy and predictability of some graft procedures (columellar strut, spreader graft). There was also a consensus about the rejection of some unusual procedures (electric-powered rasping of the dorsum, allopathic implants). However, no consensus was found in many domains, such as tip or columella management, resection of the dome, dome sutures, alar batten grafts, dorsal graft, nasal packing, pre-operative functional investigations, morphing, alar base reduction or the management of septal perforation. Our survey found a dramatic lack of agreement about rhinoplastic procedures, which remain highly dependent on the skill and experience of surgeons who favour the techniques with which they have achieved good results in the past. It also identifies a case for adopting, as in other fields of medicine, guidelines based upon consensual expert opinion and the evaluation of outcomes with appropriate and validated instruments.

The long-term added value of voiding school for children with refractory non-neurogenic overactive bladder: an inpatient bladder rehabilitation program.

INTRODUCTION & BACKGROUND: Despite adequate management, 20% of children with overactive bladder (OAB) syndrome fail to improve their bladder function. To approach the need for alternative strategies, an inpatient bladder rehabilitation 'voiding school' program was established. OBJECTIVE: The objective of this study was to evaluate the short- and long-term (1-year follow-up) outcome of this voiding school program in children with refractory OAB. In addition, the authors aimed to identify which children achieved the best outcomes with this voiding school program. STUDY DESIGN: The charts of all children (n = 357, mean age: 9.7 ± 2.0 years, 63.6% boys) with refractory OAB who attended voiding school between 2000 and 2010 were reviewed. A linear mixed model with random intercept was used to evaluate the incontinence (expressed by enuresis and daytime incontinence voiding scores) and maximal voiding volume (MVV). RESULTS & DISCUSSION: This study demonstrated an overall beneficial long-term effect of the inpatient program on day- and night-time incontinence, in which 36.6% of children achieved dryness during day- and night-time. In addition, the mean overall decline in the number of wet nights and days declined with 4 extra dry days and/or nights per week, in comparison with the level of continence before attending the voiding school program. In contrast, only a temporary increase in MVV was seen, however, without relapse incontinence. At last, the authors identified the negative impact of decreasing age, male sex, dysfunctional voiding and nocturnal polyuria on the overall outcome of the inpatient program. CONCLUSION: An inpatient rehabilitation 'voiding school' program is a successful and safe treatment modality for children with refractory OAB that results in long-term significant increase of continence, as well as amelioration in degree of severity. The worst outcomes of this voiding school program were detected in children with young age, who were boys, or had associated nocturnal polyuria, dysfunctional voiding, and/or faecal incontinence.

Belgian guidelines for the treatment of acute rhinosinusitis in general practice.

Management and treatment guidelines for rhinosinusitis and nasal polyps have been published by the European Academy for Allergy and Clinical Immunology (EAACI) task force in 2005, and have recently been updated. These guidelines are evidence-based and internationally recognized, and form the basis for the here presented "Belgian Guidelines for the treatment of ARS in general practice", developed by the sinusitis committee. This document is intended to establish evidence-based management procedures for ARS, one of the most frequent upper airway diseases, mostly treated by the general practitioner. It is recommended to treat ARS with topical glucocorticosteroids 200 mcg BID. Antibiotics are recommended for the treatment of severe ARS, if need be, together with topical glucocorticosteroids BID.

The Patient Participation Culture Tool for healthcare workers (PaCT-HCW) on general hospital wards: A development and psychometric validation study.

BACKGROUND: Patient participation is an important subject for modern healthcare. In order to improve patient participation on a ward, the ward's culture regarding patient participation should first be measured. In this study a measurement tool for patient participation culture from the healthcare worker's perspective, the Patient Participation Culture Tool for healthcare workers (PaCT-HCW), was developed and psychometrically evaluated. OBJECTIVES: The aim of this study was to develop and validate a tool that measures the healthcare worker-related factors of patient participation and information sharing and dialogue in patient participation from the healthcare worker's perspective in order to represent the patient participation culture on general and university hospital wards. DESIGN: A four-phased validation study was conducted: (1) defining the construct of the PaCT-HCW, (2) development of the PaCT-HCW, (3) content validation, and (4) psychometric evaluation. SETTINGS: The Belgian Federal Government invited all Flemish general and university hospitals by e-mail to distribute the PaCT-HCW in their organization. Fifteen general hospitals took part in the study. PARTICIPANTS: Units for surgery, general medicine, medical rehabilitation, geriatric and maternal care were included. Intensive care-units, emergency room-units, psychiatric units and units with no admitted patients (e.g. radiology) were excluded. The respondents had to be caregivers, with hands-on patient contact, who worked on the same ward for more than six months. Nursing students and other healthcare workers with short-time internship on the ward were excluded. The tool was completed by 1329 respondents on 163 wards. METHODS: The PaCT-HCW was psychometrically evaluated by use of an exploratory factor analysis and calculation of the internal consistency. RESULTS: A model containing eight components was developed through a literature review, individual interviews, and focus interviews. The developed model showed high sampling adequacy and the Bartlett's test of sphericity was significant. An exploratory factor analysis identified eight components, explaining 49.88% of the variances. The eight original included components were retained. The PaCT-HCW also showed high internal consistency. CONCLUSION: The PaCT-HCW offers an in-depth and differentiated perspective of the healthcare worker-related factors of patient participation and information sharing and dialogue in patient participation. The PaCT-HCW has been developed thoroughly, resulting in a strong, psychometric evaluated tool and is a valuable measure for both scientists and clinicians to measure these two aspects in general and university hospitals. By using the PaCT-HCW, the opportunity is created to develop specific actions to improve patient participation.

Management of chronic rhinosinusitis without polyps in adults.

Chronic Rhinosinusitis (CRS) is a group of multifactorial diseases characterised by inflammation of the mucosa of the nose and paranasal sinuses with a history of at least 12 weeks of persistent symptoms and signs despite maximal medical therapy. IgE-mediated hypersensitivity and asthma are the two most important associated factors. Diagnosis of CRS is based upon the medical history and either an endoscopy or CT scan. Initial medical treatment usually consists of the avoidance of all the contributory factors and then nasal douching and nasal steroids. If medical treatment fails, endoscopic sinus surgery is considered. The authors review the most important factors associated with CRS, the diagnostic work-up and different treatment options. They also present a rationale for treatment.

Cancer of the nasal vestibule, nasal cavity and paranasal sinuses.

The usual clinical presentation of sinonasal tumours includes symptoms that are indistinguishable from inflammatory sinus disease, namely nasal airway obstruction, pain, and epistaxis. Abnormal V1 and/or V2 sensations are a strong indication of the possibility of tumour. Computed tomography is the most reliable and informative imaging tool for evaluating the cancers of the paranasal sinuses. Magnetic resonance imaging is essential for tumour mapping because of the excellent tissue characterisation and the possibility of differentiating between neoplasms and retained secretions. A wide variety of histologies may be encountered, although squamous cell carcinoma (SCCA) is the most common. Radiation is a common adjuvant to surgery. The response of sinonasal tract tumours to radiation therapy varies with the stage and histology of the tumour. Rehabilitation after surgical resection may be accomplished with prosthodontics or reconstructive flaps. Bony erosion of the orbital walls does not constitute an indication for orbital exenteration. Patients with tumour involvement of the skull base, either in the infratemporal fossa or at the fovea ethmoidalis and cribriform plate, should be considered for craniofacial resection. Management of these tumours requires a multimodal approach, involving surgery, radiation therapy and, increasingly in recent years, chemotherapy. Management should therefore be entrusted to multidisciplinary teams only.

Computer-assisted karyotyping with human interaction.

A system for machine assisted karyotyping and chromosome analysis has been developed. The system uses a drum- or TV-scanner as input device, runs provisionally in 32 K memory, and also allows human interaction on several stages. The accuracy with which banded chromosomes are karyotyped depends strongly on the type of classifier and varies from 40 up to 80%. The accuracy of the human assisted classifier (98%) comes close to that of a skilled technician (99.5%) using manual chromosomal analysis. Due to technical and memory limitations, the time necessary for the karyotyping of one cell is too long and depends on the interaction time; however karyotyping within 5 min, including human interaction, will be possible in the near future.

Transport of artemisinin and sodium artesunate in Caco-2 intestinal epithelial cells.

Artemisinin and its derivatives are becoming interesting alternatives to the commonly used antimalarial drugs because they are efficient in treating severe and multidrug resistant forms of Plasmodium falciparum malaria. A major drawback is the occurrence of recrudescence some time after treatment. Moderate oral bioavailability has been suggested as a possible cause. As one of the factors that might limit absorption after oral administration, we studied the intestinal permeability using an in vitro system of the intestinal mucosa, Caco-2. Concentrations of artemisinin were determined by UV after alkaline degradation, while for sodium artesunate, a capillary electrophoresis method was developed. Artemisinin easily crossed the epithelial cells by passive diffusion (Papp = 30.4 +/- 1.7 x 10(-6) cm s-1, pH 7.4). Permeability of the hemisuccinate analogue, sodium artesunate, was 8-fold lower (Papp = 4.0 +/- 0.4 x 10(-6) cm s-1 at pH 7.4) and strongly dependent on pH, which might result in site dependent resorption in an in vivo situation. Enzyme catalyzed ester hydrolysis of sodium artesunate in Caco-2 monolayers to the biologically active metabolite, dihydroartemisinin, was moderate. The results indicate that the transepithelial permeability is probably not a limiting factor in the overall absorption process after oral administration of artemisinin or sodium artesunate. Solubility, dissolution rate, stability, and first-pass metabolism are suggested as alternative limiting factors.

Some statistical data about anterior rhinomanometry.A comparative study between passive anterior rhinomanometry and active anterior rhinomanometry.

The authors studied the value of the passive anterior rhinomanometry. In a first group of 28 patients it was possible to determine by a confidence interval test if the type of the airstream was mainly laminar or turbulent . In a second group of 15 test subjects the type of airstream was graphically determined. At the same time, the values of nose resistance obtained with the P.A.R. were compared to the values obtained with active anterior rhinomanometry.

Clinical efficacy of N-acetyl-aspartyl-glutamic acid nasal spray in children suffering from pollinosis: a double-blind multicentre study.

A double-blind, four-centre study was carried out in 66 children to compare the clinical efficacy and safety of N-acetyl-aspartyl-glutamic acid (NAAGA) and disodium cromoglycate (DSCG) nasal sprays. At similar dosage conditions (one puff per nostril, four times daily, for 3 weeks), no significant differences between the treatments were discernible in the primary efficacy parameters (scores, patients' and physicians' opinion). Both products induced statistically significant improvements in the nasal, ocular and total scores, but not in the respiratory (breathing) score. The hay-fever symptoms improved clinically in > 50% of the children after only two weeks with both treatments. The exact figures depended on the parameters considered. Thirteen out of 25 patients (52%) in the NAAGA group found the efficacy "good" or "excellent" at the end of the treatment period; the corresponding opinion in the DSCG group was expressed by 10 out of 24 patients (41.7%). Of the 28 patients that used the rescue medication, 12 (42.8%) were from the NAAGA group and 16 (57.1%) from the DSCG group. One patient on NAAGA treatment reported side effects, i.e. pruritus in the nose and sneezing.

Congenital nasal pyriform aperture stenosis in newborn: report on three cases.

Congenital nasal pyriform aperture stenosis (CNPAS) is recognized as a cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed by a bony overgrowth of the nasal process of the maxilla. The CNPAS may occur as an isolated congenital defect or in combination with other abnormalities. Three cases of CNPAS are reported with special attention to the clinical presentation and to the management recommendation prior to surgery. Surgical repair was performed for all these three highly symptomatic patients using a sublabial approach for drilling the nasal process in order to obtain a wider nasal vestibular patency. All of them were equipped with bilateral nasal stenting.